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Philippines Cap Cpguidelines 2010 PDF
Philippines Cap Cpguidelines 2010 PDF
2010 Update
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CAP Guidelines
PANEL OF EXPERTS
PSMID Angeles Tan-Alora, M.D.
Mediadora C. Saniel, M.D.
Thelma E. Tupasi, M.D.
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CAP Guidelines 2010 Update
TABLE OF CONTENTS
Foreword ............................................................................................. 6
Methodology ........................................................................................ 7
Introduction .......................................................................................... 10
Executive Summary............................................................................. 11
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CAP Guidelines 2010 Update
18. What should be done for patients who are not improving
after 72 hours of empiric antibiotic therapy? ................................ 68
Table 15. Factors to consider for nonresponding pneumonia
or failure to improve ...................................................... 69
19. When can a hospitalized patient with CAP be discharged? ......... 69
Table 16. Recommended hospital discharge criteria ................... 70
APPENDICES
Appendix 1. Grading system for recommendation ............................. 101
Appendix 2. Winthrop-University Hospital infectious disease
division’s point system for diagnosing Legionnaire’s
disease in adults (modified) ............................................ 102
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FOREWORD
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CAP Guidelines 2010 Update
METHODOLOGY
The evidence-based approach and formal consensus techniques
(nominal group technique and the Delphi technique) employed in this
year’s update were similar to those used during its initial development.
This approach includes the initial phase on preparation of the evidence-
based report followed by the preparation of the interim report. The interim
report was the result of review, discussion of the evidence-based report,
and consensus of the group. Consensus was defined as 70% of votes
cast, either by written ballots or by raising of hands.
The third phase was the preparation of the draft guidelines, which
resulted from an expert panel review of the interim report. This year,
the draft of the revised guidelines were presented in the following
conventions to gather comments, suggestions, and opinions from the
specialists and practitioners:
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CAP Guidelines CAP Guidelines
Institutions
Armed Forces of the Philippines Medical Center
Cebu (Velez) General Hospital, Inc.
Davao Doctors’ Hospital
Department of Health
East Avenue Medical Center
Lung Center of the Philippines
Makati Medical Center
Manila Doctors Hospital
Ospital ng Maynila Medical Center
University of Perpetual Help Rizal Medical Center
Philippine Heart Center
Research Institute for Tropical Medicine
San Lazaro Hospital
St. Luke’s Medical Center
University of the East Ramon Magsaysay Memorial Medical Center
University of the Philippines – Philippine General Hospital
University of Santo Tomas Hospital
Veterans Memorial Medical Center
Pharmaceutical companies
Abbott Laboratories
AstraZeneca
Bayer Philippines, Inc.
Biomedis-Unilab
Cathay Drug Company, Inc.
GlaxoSmithKline
Janssen Pharmaceuticals
Merck Sharp & Dohme
Natrapharm
Novartis Healthcare Philippines
Orient Euro Pharmaceuticals
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2010 Update CAP Guidelines 2010 Update
Pascual Laboratories
Pfizer Philippines, Inc.
Roche Philippines, Inc.
Sanofi Pasteur
UAP-Medichem
United Laboratories
Westmont Pharma Inc.
Wyeth Philippines, Inc.
Zuellig Pharma
The final phase was the preparation of the revised guidelines, which
were presented in the annual convention of PSMID 2009.
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CAP Guidelines
INTRODUCTION
Pneumonia is the third leading cause of morbidity (2001) and mortality
(1998) in Filipinos based on the Philippine Health Statistics from the
Department of Health. These clinical practice guidelines on community-
acquired pneumonia (CAP), specific only for the empiric therapy of
immunocompetent adults, were drafted to provide the clinician with
practical approaches in the resolution of important issues in the diagnosis,
management and prevention of CAP in adult patients.
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EXECUTIVE SUMMARY
CLINICAL DIAGNOSIS
1. Can CAP be diagnosed accurately by history and physical examination?
• The accuracy of predicting CAP by physicians’ clinical judgment is
between 60-76%. (Grade B)
• Clinical prediction rules combining history and physical examination
findings may be utilized to presumptively identify patients with
pneumonia. (Grade B)
2. Is there any clinical feature that can predict CAP caused by an atypical
pathogen?
• There is no clinical feature that can reliably distinguish pneumonia due
to a typical or an atypical pathogen. (Grade A)
CHEST RADIOGRAPHY
3. What is the value of the chest radiograph in the diagnosis of CAP?
• The chest x-ray is essential in the diagnosis of CAP, assessing severity,
differentiating pneumonia from other conditions, and in prognostication.
(Grade A)
5. Are there characteristic radiographic features that can predict the likely
etiologic agent from the chest radiograph?
• There is no characteristic radiographic feature that can predict the likely
etiologic agent in CAP. (Grade B)
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SITE-OF-CARE DECISIONS
10. Which patients will need hospital admission?
• A management-oriented risk stratification of CAP based on the patient’s
clinical presentation or condition, status of any co-morbid condition, and
chest x-ray findings should be utilized in the decision to determine the
site of care for patients. (Grade A)
• Patients with low-risk CAP are considered suitable for outpatient care in
the absence of contraindications. (Grade A)
• Patients with moderate- and high-risk CAP need to be hospitalized for
closer monitoring and/or parenteral therapy. (Grade A)
MICROBIOLOGIC STUDIES
11. What microbiologic studies are necessary in CAP?
• In low-risk CAP, microbiologic studies are optional. (Grade B)
• In moderate- and high-risk CAP, blood cultures and Gram stain and
culture with antibiotic sensitivity tests of respiratory specimens should
be done in laboratories with quality assurance. (Grade A)
• When possible, tests to document the presence of Legionella pneumophila
are recommended for hospitalized CAP. (Grade B)
• Invasive procedures (i.e., transtracheal, transthoracic biopsy,
bronchoalveolar lavage, protected brush specimen) to obtain specimens
for special microbiologic studies for atypical pathogens (e.g.,
mycobacteria and other microorganisms that will not grow on routine
culture) are options for non-resolving pneumonia, immunocompromised
patients, and patients in whom no adequate respiratory specimens can be
sent despite sputum induction and routine diagnostic testing. (Grade B)
TREATMENT
12. When should antibiotics be initiated for the empiric treatment of CAP?
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CAP Guidelines 2010 Update
13. What initial antibiotics are recommended for the empiric treatment of CAP?
• For low-risk CAP without comorbid illness, amoxicillin remains
the standard drug of choice (Grade A). Extended macrolides are
recommended when atypical pathogens are suspected. (Grade A)
• For low-risk CAP with stable comorbid illness, β-lactam with β-
lactamase inhibitor combinations (BLIC) (Grade A) or second-generation
cephalosporins (Grade A) with or without extended macrolides are
recommended. For patients who have completed first-line treatment
(BLIC or second-generation cephalosporin) with no response, an
extensive work-up should be done to identify the factors for failure of
response. Work-up may include doing sputum Gram stain and culture.
An alternative treatment is an oral 3rd generation cephalosporin (i.e.,
cefdinir, cefixime, cefpodoxime proxetil) with or without extended
macrolides. (Grade C)
• For moderate-risk CAP, a combination of an IV non-antipseudomonal
β-lactam (BLIC, cephalosporin or carbapenem) with either an extended
macrolide or respiratory fluoroquinolone is recommended as initial
antimicrobial treatment. (Grade B)
• For high-risk CAP without risk for Pseudomonas aeruginosa,
a combination of an IV non-antipseudomonal β-lactam (BLIC,
cephalosporin or carbapenem) with either an IV extended macrolide or IV
respiratory fluoroquinolone is recommended as an initial antimicrobial
treatment. (Grade A)
• For high-risk CAP with risk for P. aeruginosa, a combination of an IV
antipneumococcal, antipseudomonal β-lactam (BLIC, cephalosporin or
carbapenem) with an extended macrolide and aminoglycoside (Grade A)
or a combination of an IV antipneumococcal, antipseudomonal β-lactam
(BLIC, cephalosporin or carbapenem) and IV ciprofloxacin or high dose
IV levofloxacin. (Grade B)
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16. Which oral antibiotics are recommended for de-escalation or switch therapy
from parenteral antibiotics?
• The choice of oral antibiotics following initial parenteral therapy is based
on available culture results, antimicrobial spectrum, efficacy, safety, and
cost. In general, when switching to oral antibiotics, either the same agent
as the parenteral antibiotic or the same drug class should be used.
18. What should be done for patients who are not improving after 72 hours of
empiric antibiotic therapy?
• The clinical history, physical examination, and the results of all available
investigations should be reviewed. The patient should be reassessed for
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CAP Guidelines 2010 Update
PREVENTION
20. How can CAP be prevented?
• Influenza vaccination is recommended for the prevention of CAP. (Grade
A)
• Pneumococcal vaccination is recommended for the prevention of
invasive pneumococcal disease in adults. (Grade A)
• Smoking cessation is recommended for all persons with CAP who
smoke. (Grade A)
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CAP Guidelines
SUMMARY OF EVIDENCE
CAP is commonly defined as an acute infection of the
pulmonary parenchyma with symptoms of acute illness
accompanied by abnormal chest findings. Patients who acquire
the infection in hospitals or long-term facilities are typically
excluded from the definition.1 There is reported significant inter-
observer agreement among physicians in obtaining clinical
symptoms and signs in diagnosing patients with possible
CAP.2,3,4 Furthermore, elderly patients may not present with the
classical symptoms of fever, cough, and dyspnea.5
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Decision Basis Physician’s Heckerling et. al. Gennis et. al. Rule
Clinical Score (threshold (threshold was 1
Judgment was 2 points) point)
The initial CAP guidelines by the American Thoracic Society have clearly
stated that symptoms cannot be reliably used to establish the etiologic diagnosis
of pneumonia (typical or atypical pathogen)13. According to these guidelines,
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the clinical presentation of pneumonia may vary because of three reasons: the
virulence factors of the pathogens; the advanced age of the host; and the presence
of coexisting illnesses of the host. These reasons result in an overlap of clinical
symptoms among the pathogens10. Furthermore, mixed organisms may cause
approximately 5-38% cases of CAP14.
SUMMARY OF EVIDENCE
Atypical pathogens are a common cause of CAP in all
regions of the world with a global incidence of 22%15. The main
feature differentiating atypical from typical CAP pathogens is the
presence of extrapulmonary findings16. Pneumonia caused by
typical pathogens (Streptococcus pneumoniae, Haemophilus
pneumoniae, or Moraxella catarrhalis) present with clinical
findings limited to the lungs. Each of the atypical pathogens
commonly implicated in CAP (Mycoplasma pneumoniae,
Chlamydophila pneumoniae, and Legionella) has a predilection
for certain extrapulmonary organ systems (GI, cutaneous).
Therefore, the presence of the extrapulmonary findings can
help the clinician narrow down the diagnostic possibility of CAP
due to an atypical pathogen.
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CAP Guidelines 2010 Update
REFERENCES
1. Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice
Guidelines for the Management of Community-acquired Pneumonia in adults.
Infectious Disease Society of America. Clin Infect Dis 2000; 31:347-82.
2. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired
pneumonia? Diagnosing pneumonia by history and physical examination. JAMA
1997; 278: 1440-5.
3. Wipf JE, Lipsky BA, Hirschmann JV, et al. Diagnosing pneumonia by physical
examination: relevant or relic? Arch Intern Med 1999; 159: 1082-7.
4. Spiteri MA, Cook DG, and Clarke SW. Reliability of eliciting physical signs in
examination of the chest. Lancet 1988; 1 (8590): 873-5.
7. Gennis P, Gallagher J, Falvo C, Baker S, Than W. Clinical criteria for the detection of
pneumonia in adults: guidelines for ordering chest roentgenograms in the emergency
department. J Emerg Med 1989; 7: 263-268.
8. Singal BM, Hodges JR, Radack KL. Decision rules and clinical prediction of
pneumonia: evaluation of low-yield criteria. Ann Emerg Med 1989; 18: 13-20.
9. Heckerling PS, Tape TG, Wigton RS, et al. Clinical prediction rule for pulmonary
infiltrates. Ann Intern Med 1990: 113: 664-670.
10. Metlay JP, Fine MJ. Testing strategies in the initial management of patients with
community-acquired pneumonia. Ann Intern Med 2003; 138: 109-118.
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CAP Guidelines
11. Sackett DL. A primer on the precision and accuracy of the clinical examination.
JAMA 1992; 267 (19): 2638-2644.
12. Jaeschke R, Guyatt G, Sackett DL. Users’ guides to the medical literature. III. How to
use an article about a diagnostic test. B. What are the results and will they help me in
caring for my patients? The Evidence-based medicine Working Group. JAMA 1994;
271: 703-7.
13. Niederman MS, Mandell LA, Anzueto A. et al. American Thoracic Society Guidelines
for the initial management of adults with community-acquired pneumonia: diagnosis,
assessment of severity, and initial antimicrobial therapy Am Rev Respir Dis 1993;
148: 1418-1426.
14. Armitage K, Woodhead M. New guidelines for the management of adult community-
acquired pneumonia by Kathryn Armitage and Mark Woodhead. Curr Opin Infect Dis
20: 170-176 2007
15. Arnold FW, Summersgill JT, LaJole AS, Peyran P, Marrie TJ, Rossi P, Blasl F,
Fernandez P, File TM, Rello J, Menendez R, Maezoratti L, Luna CM, Ramirez J,
and the Community-acquired Pneumonia Organization (CAPO) Investigators. A
worldwide perspective of atypical pathogens in community-acquired pneumonia. Am
J Respir Crit Care Med 2007; 175: 1086-1093.
16. Cunha, Burke A. The atypical pneumonias: clinical diagnosis and importance. Clin
Microbiol Infect 2006; 12: 12-24.
17. Marrie TJ, Peeling RW, Fine MJ. et al. Ambulatory patients with community-acquired
pneumonia: The frequency of atypical agents and clinical course. Am J Med 1996;
101: 508-515.
18. Fang GD, Fine M, Orloff J. et al. New and emerging etiologies for community-
acquired pneumonia with implications for therapy: A prospective multicenter study
of 359 cases. Medicine (Baltimore) 1990; 69: 307-316.
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CAP Guidelines 2010 Update
22. Cunha, Burke A. Severe Legionella pneumonia: rapid presumptive diagnosis with
Winnthrop-University hospital’s weighted point score system (modified). Heart Lung
2008; 37: 311-320.
23. Diederen BMW. Legionella spp. and Legionnaires’ disease. Journal of Infection
2008; 56: 1-12.
24. Edelstein PH. Legionnaire’s disease. Clin Infect Dis 1993; 16: 741-9.
27. Pedro-Bote ML, Sabria M. Legionellosis. Semin Resp Crit Care Med 2005; 625-34.
29. Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ disease: 25 years of
investigation. Clin Microbiol Rev 2002; 15: 506-26.
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A posteroanterior radiograph places the patient with his or her chest against
the film, minimizing the magnification of the heart and the mediastinum on the
image, thus minimizing the amount of lung obscured by these structures. Similarly,
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CAP Guidelines 2010 Update
on the lateral view, the size of the heart on the image is minimized if the left side
is against the film. The left-lateral is therefore the preferred position for the lateral
view.2 If pneumonia is localized on the postanterior view, the specific lateral view
should be requested. Additional supplemental views such as lordotic, coned, or
oblique views may be done to further evaluate regions that may not be readily
seen in the routine studies.
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CAP Guidelines
For patients who are hospitalized for suspected pneumonia but have initial
negative chest radiography findings, it may be reasonable to treat their condition
presumptively with antibiotics and repeat the imaging in 24 to 48 hours.1
• The chest CT scan has no routine role in the evaluation of CAP. (Grade
B)
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CAP Guidelines 2010 Update
SUMMARY OF EVIDENCE
Physicians’ ability to assess CAP on clinical grounds is low
and cannot replace chest radiographs.4 Consensus statements
from professional organizations strongly recommend the need
for chest radiography to confirm the diagnosis of CAP.5,6 In
addition, the chest radiograph is requested to detect associated
lung disease, to gain insight into the causative agent (in some
cases), to assess severity, and to obtain a baseline to assess
response.5 A different recommendation from a British study
suggests that chest radiographs be performed only when there
are focal chest signs, when the symptoms worsen with antibiotic
therapy, or when recovery is slower than expected.7
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*Confidence Interval
REFERENCES
1. Mandell LA, Wunderink RG, Anzueto A. et al. Infectious Diseases Society of
America/ American Thoracic Society Consensus Guidelines on the Management of
Community-acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44:
S27-72.
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CAP Guidelines 2010 Update
5. Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice
Guidelines for the Management of Community-acquired Pneumonia in adults.
Infectious Disease Society of America. Clin Infect Dis 2000; 31:347-82.
6. Niederman MS, Mandell LA, Anzueto A, et. al. American Thoracic Society Guidelines
for the management of adults with community-acquired pneumonia. Diagnosis,
assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care
Med 2001; 163: 1730-1754.
7. Macfarlane JT. Lower respiratory tract infection and pneumonia in the community.
Semin Respir Infect 1999; 14: 151-162.
11. Fine MJ, Smith DN, Singer DE. Hospitalization decision in patients with community-
acquired pneumonia: a prospective cohort study. Am J Med 1990;89:713-21.
12. Dans PE, Charache P, Fahey M, Otter SE. Management of pneumonia in the
prospective payment era: a need for more clinician and support service interaction.
Arch Intern Med 1984; 144:1392-7.
13. Fine MJ, Smith MA, CarsonCA, et al. Prognosis and outcomes of patients with
community-acquired pneumonia; a meta-analysis. JAMA 1996; 275(2): 134-140.
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CAP Guidelines
Low-risk CAP: Adult patients with stable vital signs (Respiratory Rate
(RR) <30 breaths/minute, Pulse Rate (PR) <125 beats/minute, Temperature
>36oC or <40oC, Systolic Blood Pressure (SBP) >90 mmHg, and Diastolic Blood
Pressure (DBP) >60 mmHg) are associated with low morbidity and mortality rate
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CAP Guidelines 2010 Update
of 1-3% and are thus categorized as low-risk CAP. These patients are considered
suitable for out-patient care in the absence of contraindications.
No altered mental state of acute altered mental state of acute onset Need for mechanical ventilation
onset
No suspected aspiration Suspected aspiration
No or stable comorbid conditions Decompensated co-morbid
condition
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CAP Guidelines
High-risk CAP: Patients with any of the criteria under the moderate-
risk CAP category plus signs of severe sepsis / septic shock or who need for
mechanical ventilation are associated with higher mortality rate of 20-30% and
are thus categorized as High-risk CAP warranting admission in the intensive
care unit.
CAP
NO Moderate-risk
CAP
Low-Risk CAP
Ward
Admission
Outpatient
SUMMARY OF EVIDENCE
The decision regarding site of care—whether the patient
should be treated as an outpatient, in a hospital ward, or in the
ICU—carries with it a number of important implications. It often
determines the type and extent of diagnostic testing, the choice,
spectrum and route of administration of antimicrobial therapy,
the intensity of clinical observation, and the overall treatment
costs.1,2,3
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REFERENCES
1. Mandell L. Severe CAP and the IDSA/ATS CAP Guidelines Prediction Rule:
Validated or Not; CID 2009: 48: 386-8.
2. Liapikao A et al. Severe CAP: Validation of the IDSA/ATS CAP Guidelines to Predict
an ICU admission; CID 2009: 48: 377-85.
3. Angus DC, Marrie TJ, Obrosky DS et al. Severe CAP: use of intensive care services
and evaluation of the American and British Thoracic Society Diagnostic Criteria. Am
J Respir Crit Care Med 2002; 166: 717-23.
6. Ewig S and Welte T. CRB- 65 for the assessment of Pneumonia severity: Who could
ask for more? Thorax. Aug 2008 63(8): 665-6.
8. Pasamba CQ, Cadena EV. The Applicability of CURB-65 as a Prognostic Tool for
CAP Among In-patients in the Medical Ward of Dr. Jose Reyes MMC: a 3 Year
Retrospective Study. (unpublished)
10. Tabaloc MJ. Medical Outcomes and Process of Care of Adult Patients with CAP by
Pneumonia PORT, Chong Hua Hospital, July 2003-June 2004. (unpublished)
11. Myint PK, Kamath AV, Vowler SL et al. Severerity Assessment criteria recommended
by the BTS for CAP and older patients. Should SOAR (SBP, Oxygenation, age and
RR) criteria be used in older people? A compilation study of 2 prospective cohorts.
Age and Ageing 2006; 35: 286-91.
12. Kothe H, Bauer T, Marrie R et al. Outcome of CAP: influence of age, residence status
& antimicrobial treatment. Eur Repir J 2008 Jul; 32(1): 139-46.
13. Brito V, Niederman M.S., How can we improve the management and outcome of
pneumonia in the elderly? Eur Respir J 2008; 32; 12-4.
14. Marrie TJ, Durant H and Yates L. CAP requiring hospitalization: 5 year prospective
study. Rev Infect Dis 1989; 11(4): 586-99.
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CAP Guidelines
15. Fine MJ. Hospitalization decisions in patients with CAP: a prospective cohort study.
Am J Med 1990; 89:713-21.
16. Fine MJ, Auble TE, Yealy DM et al. A Prediction Rule to Identify low-risk patients
with CAP. N Engl J Med 1997; 336: 243-50.
17. Halm EA, Atlas SJ Borowsky LH et al. Understanding physician adherence with a
pneumonia practice guideline: effects of patient, system and physician factors. Arch
Int Med 2000; 160: 98-104.
18. Niederman MS and Brito V. Pneumonia in the Older Patient. Clin Chest Med 2007;
28: 751-71.
19. Rello J, Rodriguez A, Torres A et al. Implications of COPD in patients admitted to the
ICU by CAP. Eur Respir J 2006; 27:1210-16.
20. Molinos L, Clemente MG, Miranda B et al. CAP in patients with and without COPD.
J Infect 2009. Mar 14
21. Arnold FW, Ramirez JA, McDonald LC et al. Hospitlaization for CAP: the PSI versus
Clinical Judgement. Chest 2003; 124:121-4.
22. Marras TK, Gutierrez C, Chan CK. Applying Prediction Rule to Identify low-risk
patients with CAP.Chest 2000; 118:1339-43.
23. The American Thoracic Society. Guidelines for the Initial Management of Adults
with CAP: Diagnosis, Assessment of Severity; and Initial Antimicrobial Therapy. Am
J Respir Dis 1993; 13:1418-26.
24. Minohue MF, Coley CM, Fine MJ et al. Patients hospitalized after initial outpatient
treatment for CAP. Ann Emerg Med 1998; 21(3): 276-80.
25. Marrie TJ, Durant H, Yates L. CAP requiring hospitalization: 5 year prospective
study. Rev Infect Dis 1989; 11: 586-99.
26. Torres A, Serra J, ferrer A et al. Severe CAP: etiology, epidemiology & prognostic
factors. Am Rev Respir Dis 1991; 144: 312-8.
27. Moine P, Vercken JP, Chevret S et al. Severe CAP: etiology, epidemiology &
prognostic factors. Chest 1994; 105:1487-95.
28. Shariatzadeh MR, Huang JQ, Marrie TJ. Differences in features of aspiration
Pneumonia according to site of acquisition: community or continuing care facility. J
Am Geriatrc Soc 2006; 54:296-302.
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CAP Guidelines 2010 Update
30. Lim WS, Van der Eerden M, Laing R et al. Defining CAP severity on presentation to
Hospital: an International and Validation study. Thorax 2003; 58: 377-82.
31. Chalmers JD, Singanayagam A, Hill AT. Systolic BP is superior to other Haemodynamic
predictors of outcome in CAP. Thorax 2008; 63: 698-702.
32. Metlay JP, Fine M. Testing Strategies in the Initial Management of patients with CAP.
Ann Int Med 2003; 138 (2): 109-18.
33. Charles P, Wolfe R, Whitby M t al. SMART-COP: A Tool for Predicting the Need for
Intensive Respiratory or vasopressor Support in CAP; CID 2008; 47: 375-84.
34. The BTS and the Public Health Lab Service. CAP in Adults in British Hospitals in
1982-83: a survey of aetiology, mortality, prognostic factors and outcome. QJ med
1987; 62: 195-220.
35. Farr BM, Sloman AJ, Fisch MJ, Predicting death in patients hospitalized for CAP.
Ann Int Med 1991; 115: 428-36.
36. Janssens JP, Gauthey L, Hermann F et al. CAP in older patients. J Am Geriatrc Soc
1996; 44: 539-44.
37. Rello J, Rodriguez A, Lisboa T et al. PIRO score for CAP: A new prediction rule for
assessment of severity in ICU patients with CAP. Crit Care Med 2009; 37: 456-62.
39. Niederman M. Making Sense of Scoring Systems in CAP. Respirology 2009. 14:327-
35.
40. Sin DD, Man SF, Marrie TJ. Arterial Carbon Dioxide Tension on admission as a
marker of in-hospital mortality in CAP. Am J Med 2005 Feb; 118 (2):145-50.
41. Lee J, Ryu Y, Chun E, et al. Outcomes and Prognostic Factors for Severe CAP that
requires mechanical ventilation. The Korean J of Internal Medicine; 2007:22: 157-
64.
42. Ray P, Birolleau S, Lefort Y et al. Acute Respiratory Failure in the elderly: etiology,
emergency diagnosis and Prognosis. Crit Care 2006; 10 (3)/R 82
43. Confalonieri M, Potena A, Carbone G et al. Acute Respiratory Failure with Severe
CAP. Am J respire Crit Care Med 1999; 160:1585-91.
44. Ewig S, Ruiz M, Mensa J et al. Severe CAP: assessment of severity criteria. A J
Respir Crit Care Med 1998; 158: 1102-8.
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CAP Guidelines
45. ATS: Guidelines for the management of Adults with CAP: diagnosis, assessment of
severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001;
163: 1730-54.
46. Dellinger RP, Levy M, Carlet J, et al. Surviving Sepsis Campaign: International
Guidelines for management of Severe Sepsis and Septic Shock 2008: Intensive Care
Med 2008; 34:17-60.
47. Dremsinov T, Clermont G, Kellum J et al. Severe sepsis in CAP: when does it happen,
& do SIRS criteria help predict course? Chest 2006; 129; 968-78.
48. Yoshimoto A, Nakamura H, Fujimora M et al. Severe CAP in an ICU: risk factors for
mortality. Intern Med 2005; 44: 710-6.
49. Schaaf B, Kruse J, Rupp J et al. Sepsis severity predicts outcome in community
acquired pneumococcal pneumonia Eur Respir J 2007 Sept; 30(3); 517-24; 2008 Feb;
31(2): 478-9.
50. White M, Mankan A, Lawless M et al. Mortality in Humans with Pneumonia and
sepsis Is related to an Uncompensated Anti-Inflammatory response to Infection. Arch
Int Med 2008; 168 (13): 1468-9.
51. Aujesky D, McCausland JB, Whittle J, Obrosky D, Yealy D, Fine M. reasons Why
Emergency department providers Do Not rely on the PSI to determine the Initial Site
of treatment for patients with Pneumonia. CID 2009; 49:e100-8.
52. Labarere J, Stone RA, Scott OD et al. Factors associated with the Hospitalization
of low-risk patients with CAP in a cluster-randomized trial. J Gen Intern med 2006;
21:745-52.
53. Fine MJ, Hough LJ, Medsger AR et al. The Hospital Admission Decision for patients
with CAP. Results from the pneumonia Patient Outcomes research Team cohort
study. Arch Int Med 1997; 157: 36-44.
54. Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK<feagan BG. A controlled
trial of a critical pathway for treatment of CAP. CAPITAL Study Investigators. CAP
Intervention trial assessing Levofloxacin. JAMA 2000; 283:749-55.
55. The British Thoracic Society Guidelines for the management of CAP in Adults,
Update 2009.
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CAP Guidelines 2010 Update
Since clinical signs and symptoms including radiologic findings are not
specific for the microbial etiology of CAP, an etiologic agent should always be
sought. The conditions which can alter response to standard antibiotic management
are the presence of: 1) a bacterial etiology not covered by the empiric antibiotic
2) drug resistance and 3) etiologies other than bacteria (e.g., Mycobacterium
tuberculosis, fungi, and viruses).
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CAP Guidelines
low sensitivity, a positive blood culture is specific and is considered the gold
standard in the etiologic diagnosis of bacterial pneumonia. Gram stain and culture
of appropriate respiratory secretions should also be part of the initial work up.
Diagnostic testing is recommended when the results are likely to change the
standard empiric antibiotic management. The cost effectiveness of the diagnostic
tests should also be taken into consideration.
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CAP Guidelines 2010 Update
This data shows that atypical pathogens can be found as etiologic agents in
all risk classes of CAP (Table 5).
In and out-patient
Asia/African 10 20 12 5 6
Asia 11 25.2 11 13.4 1.1
In-patient
Philippines 12 23.5 12.2 4.7 6.6
Philippines 13 43 14.2 12.8 27
In Asian countries, it is of note that only 7 out of the 648 urine specimens
collected for Legionella UAT (1.1%) were positive11. The prevailing serotype in
Asia may not be serotype 1 which is the only serotype the UAT detects.
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CAP Guidelines
SUMMARY OF EVIDENCE
Definite etiology: The etiologic diagnosis is considered
definite when the pathogen is isolated from normally sterile or
uncontaminated specimens (blood, pleural fluid or secretions
obtained from transtracheal or transthoracic aspiration).
Pathogens such as M. tuberculosis, L. pneumophila, viruses,
and fungi are not normal colonizers of the upper airway; thus,
they are considered definite etiologic agents of pneumonia
when isolated from respiratory secretions. 15
46
CAP Guidelines 2010 Update
47
CAP Guidelines
REFERENCES
1. Marrie TJ, Paulin-Costello M, Beecroft MD, Hernan Z. Etiology of community-acquired
pneumonia treated in an ambulatory setting. Respir Med 2005 Jan;99(1):60-5.
4. Song JW, Park SC, Choi Y et al. Atypical Pathogens as etiologic agents in hospitalized
patients with community-acquired pneumonia in Korea: A prospective multi-center
study. J Korean Med Sci 2006;21:602-7.
5. Ortiz MF, Comia CT. Adherence of the physicians at Mary Mediatrix Medical Center
to the 2004 Philippine Guidelines on the Management of Patients Hospitalized for
CAP. (unpublished).
6. San Diego DC, Galvez BB, Balanag VM, Naval S. Philippine clinical practice
guidelines of high risk CAP: a surveillance study (unpublished)
10. Arnold FW, Summersgill JT, Lajoie AS et al. A worldwide perspective of atypical
pathogens in community acquired pneumonia. Am J Respir Crit Care; 2007:
175:1086-1093.
11. Jae-Hoon Soong, Won Sup Oh, Cheol-In Kang et al. Epidemiology and clinical
outcomes of community acquired pneumonia in adult patients in Asian countries: a
prospective study by the Asian network for surveillance of resistant pathogens. Int J
Antimicrobial Agents 31 (2008) 107-114.
12. Ngeow YF, Suwanjutha S, Chantarojanasriri T et al. An Asian study on the prevalence
of atypical respiratory pathogens in community acquired pneumonia. J Infect Dis.
2005; 9 (3): 144-53.
48
CAP Guidelines 2010 Update
13. Ecarma RM. Alejandria M and Saniel M Prevalence and predictors of atypical
pathogens in hospitalized patients with community-acquired pneumonia in the
Philippines, 2002. (unpublished).
15. Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice
guidelines for the management of community-acquired pneumonia in adults.
Infectious Disease Society of America. Clin Infect Dis 2000; 31:347-82.
18. Smith MD, Derrington P, Evans R et al. Rapid diagnosis of bacteremic pneumococcal
infections by using Binax NOW streptotoccus urinary antigen test: a prospective,
controlled clinical evaluation. J Clin Microbiol 2003;41(7):2810-3.
19. Smith, MD, Shepard CL, Hogan A et al. Diagnosis of Streptococcus pneumoniae
infections in adults with bactermia and community acquired pneumonia: clinical
comparison of pneumococcal PCR and urinary antigen detection. J Clin Microbiol
2009;47(4):1046-9.
20. Thorsteinsson S, Musher D, Fagan T. The diagnostic value of sputum culture in acute
pneumonia. JAMA 1975; 233(8):894-95.
22. File TM, Tan JS, Pflouffe, JE. Lower respiratory tract infections: the role of atypical
pathogens: Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella
pneumophila in respiratory infection. Infect Dis Clin N Am 1998 (12): 3.
23. Campbell LA, Kuo CC. Cultivation and laboratory maintenance of Chlamydia
pneumoniae. Curr Protoc Microbiol. Curr Protoc Microbiol 2009. Chap 11.
49
CAP Guidelines
50
CAP Guidelines 2010 Update
Low-risk CAP: In previously healthy adult patients judged to have low-risk CAP,
Streptococcus pneumoniae and Haemophilus influenzae are the predominant etiologic
agents in more than half of the cases where a pathogen is identified.4 Amoxicillin is
considered to be the standard regimen for these patients’ outpatient care.
51
CAP Guidelines
Previously healthy:
Low- risk CAP Streptococcus pneumoniae
Haemophilus influenzae amoxicillin
Chlamydophila pneumoniae OR
Mycoplasma pneumoniae extended macrolidesa
Moraxella catarrhalis (suspected atypical pathogen)
Enteric Gram-negative bacilli
(among those with co- With stable comorbid illness:
morbid illness) β-lactam/β-lactamase inhibitor
combination (BLIC)b or
second-generation oral
cephalosporinsc +/- extended macrolides
Alternative:
third-generation oral cephalosporind
+/-
extended macrolide
Moderate-risk CAP Streptococcus pneumoniae IV non-antipseudomonal β-lactam
Haemophilus influenzae (BLIC, cephalosporin or carbapenem)e
Chlamydophila pneumoniae + extended macrolide
Mycoplasma pneumoniae
Moraxella catarrhalis OR
Enteric Gram-negative bacilli
Legionella pneumophila IV non-antipseudomonal β-lactam
Anaerobes (among those with (BLIC, cephalosporin or carbapenem)e
risk of aspiration) + respiratory fluoroquinolonesf (FQ)
52
CAP Guidelines 2010 Update
53
CAP Guidelines
β-lactams: Second-generation
cephalosporin
Amoxicillin 500 mg TID Cefaclor 500 mg TID or
750 mg BID
Macrolides Cefuroxime axetil 500 mg BID
Azithromycin dihydrate 500 mg OD
Clarithromycin 500 mg BID Third-generation
cephalosporin
Moderate-risk CAP
Macrolides Second-generation
cephalosporin
Azithromycin dihydrate, 500 mg q24h Cefotiam, IV 1 gm q8h
PO/IV
Clarithromycin, PO/IV 500 mg q12h Cefoxitin, IV (with 1-2 gm q8h
anaerobic activity)
Erythromycin, PO/ IV 0.5-1 gm q6h Cefuroxime Na, IV 1.5 gm q8h
Antipneumococcal Third-generation
fluoroquinolones cephalosporin
Levofloxacin PO/IV 500-750 mg q24h Cefotaxime, IV 1-2 gm q8h
Moxifloxacin PO/IV 400 mg q24h Ceftizoxime, IV (with 1-2 gm q8h
anaerobic activity)
β-lactam with β-lactamase Ceftriaxone, IV 1-2 gm q24h
inhibitor combination
(BLIC)
Amoxicillin-clavulanic 1.2 gm q8h Carbapenem
acid, IV
Ampicillin-sulbactam, IV 1.5 gm q8h Ertapenem, IV 1 gm q24h
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CAP Guidelines 2010 Update
Macrolides Non-antipseudomonal
Azithromycin dihydrate 500 mg q24h carbapenem
Clarithromycin 500 mg q12h Ertapenem 1 gm q24h
Erythromycin 0.5-1 gm q6h
Antipseudomonal,
Antipneumococcal anti-pneumococcal
fluoroquinolones β-lactams (BLIC,
Levofloxacin 750 mg q24h cephalosporin,
carbapenem)
Moxifloxacin 400 mg q24h Cefoperazone-sulbactam 1.5-3 gm q8-12h
Piperacillin-tazobactam 2.25-4.5 gm q6-8h
Aminoglycosides Ticarcillin-clavulanic acid 3.2 gm q6h
Amikacin 15 mg/kg q24h Cefepime 2 gm q8-12h
Gentamicin 3 mg/kg q24h Cefpirome 2 gm q12h
Netilmicin 7 mg/kg q24h Imipenem-cilastatin 0.5-1 gm q6-8h
Tobramycin 3 mg/kg q24h Meropenem 1-2 gm q8h
Non-antipseudomnonal Anti-pseudomonal
BLIC fluoroquinolones
Amoxicillin-clavulanic acid 1.2 gm q6-8h Ciprofloxacin 400 mg q12h
Ampicillin-sulbactam 1.5 gm q6-8h Levofloxacin 750 mg q24h
Non-antipseudomonal
third-generation
cephalosporin Others:
Cefotaxime IV 1-2 gm q8h Oxacillin (Staphylococcus) 1-2 gm q4-6h
Ceftizoxime IV (with 1-2 gm q8h Clindamycin (Staphylo- 600 mg q6-8h
anaerobic activity) coccus and anaerobes)
Ceftriaxone IV 1-2 gm q24h Metronidazole (anaerobes) 500 mg q6-8h
Linezolid (MRSA) 600 mg q12h
Vancomycin (MRSA) 1 gm q12h
55
CAP Guidelines
56
CAP Guidelines 2010 Update
Other new antibiotics and new drug formulation potential for use in
CAP: This section summarizes the information about other antibiotics that are
available in the Philippine market that have the potential for use in the treatment
of respiratory tract infection but with limited clinical data.
57
CAP Guidelines
SUMMARY OF EVIDENCE
Initial management decisions on an empiric basis must
be made rapidly with a presumptive diagnosis of CAP.13 S.
pneumoniae, H. influenzae and atypical pathogens have been
demonstrated as the most common causes of low-risk CAP
suitable for outpatient care.
58
CAP Guidelines 2010 Update
2004 0 0 25 1.2
2005 10.3 19.6 15.1 0
2006 9.3 14 15.9 0
2007 11.1 8 13.4 0
2008 10.3 15.4 22 0
59
CAP Guidelines
60
CAP Guidelines 2010 Update
61
CAP Guidelines
62
CAP Guidelines 2010 Update
63
CAP Guidelines
64
CAP Guidelines 2010 Update
Table 12. Antibiotic dosage of oral agents for streamlining or switch therapy*
65
CAP Guidelines
Pharmacoeconomic benefits
66
CAP Guidelines 2010 Update
18. What should be done for patients who are not improving after 72
hours of empiric antibiotic therapy?
67
CAP Guidelines
In patients who are seen after the antibiotic therapy has already been initiated,
if the choice is among the recommended options and the dose is correct but the
patient has not improved after 72 hours, then the antibiotic should be changed. If
the dose is inadequate, the dose should be corrected and the drug continued.
68
CAP Guidelines 2010 Update
During the 24 hours before discharge, the patient should have the
following characteristics (unless this represents the baseline status):
1. temperature of 36-37.5o C
2. pulse < 100/min
3. respiratory rate between 16-24/minute
4. systolic BP >90 mmHg
5. blood oxygen saturation >90%
6. functioning gastrointestinal tract
SUMMARY OF EVIDENCE
Parameters of treatment response. Predicted response
to antibiotic treatment takes into account the immunologic
capacity of the host, the severity of the illness, the pathogen and
chest radiographic findings. Specifically, the clinical response
to treatment depends on a combination of several factors
particularly host factors (e.g., immune status and comorbid
conditions), bacteriologic factors (e.g. virulence, susceptibility
to antibiotics and amount of inoculum), disease factors (e.g.,
extent of illness and physiologic compromise and the degree
of disease progression at the time of diagnosis), and treatment
factors (e.g., timing and adequacy of treatment, pharmacokinetics
of the selected antibiotic). In immunocompetent CAP patients,
a subjective response is usually noted within 1 to 3 days of
initiation of treatment. Among the clinical parameters of
response to therapy, the most carefully documented response is
fever or time to defervescense.95 Fever associated with severe
pneumonia has been observed to decline in 72 hours and to
completely lyse in 5 days.96 Leukocytosis usually resolves by
day 4.97 In a prospective multicenter evaluation of more than
1400 patients with CAP admitted to 15 Spanish hospitals, the
median time to clinical stability was 4 days with stability defined
as absence of fever (temperature <37.2 °C), heart rate of <100
beats/min, respiratory rate of <24 breaths/min, systolic blood
pressure of >90 mmHg and oxygen saturation of >90% or arterial
oxygen partial pressure of >60mmHg.98 In this observational
study the initial factor associated with earlier clinical stability
69
CAP Guidelines
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CAP Guidelines 2010 Update
71
CAP Guidelines
72
CAP Guidelines 2010 Update
REFERENCES
1. Philippine Clinical Practice Guidelines on the Diagnosis, Empiric Management and
Prevention of Community-acquired Pneumonia in Immunocompetent Adults 2004
Update – Joint Statement of the Philippine Society for Microbiology and Infectious
Diseases, Philippine College of Chest Physicians and Philippine Academy of Family
Physicians.
73
CAP Guidelines
4. Taguinod-de los Reyes MC, Mendoza MT, Saniel MC. Open-labeled randomized
controlled trial and economic evaluation of azithromycin in the outpatient treatment
of community-acquired pneumonia in adults. Section of Infectious Disease, UP PGH,
1998 (unpublished).
6. Harrison TS and Keam SJ. Azithromycin extended release – a review of its use in the
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Adis Drug Evaluation 2007;67(5):773-92.
8. Center for Pharmacology and Analysis (CEPHA s.r.o.). A single center, open
randomized, two way, cross over bioequivalence study on azithromycin 500mg film-
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tablet (Pfizer Italiana S.p.A., Italy) in healthy volunteer. 2002. (Unpublished)
10. Galvez, BB. A multicenter randomized controlled trial comparing the efficacy
and safety of oral preparations of amoxicillin (500mg) + sulbactam (500mg) vs
amoxicillin (500mg) + clavulanate (125mg) in the treatment of low-risk community-
acquired pneumonia in adult Filipino patients. 2009 (unpublished)
74
CAP Guidelines 2010 Update
16. Holm A, Nexoe J, Bistrup LA et al. Aetiology and prediction of pneumonia in lower
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19. Woodhead M. Prospective study of the etiology and outcome of pneumonia in the
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20. Mundy LM, Oldah D, Auwaerten PG, et al. Implications for macrolide treatment in
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21. Niederman MS, Mandell LA, Anzueto A, et. al. American Thoracic Society guidelines
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23. Calver, AD, Walsh NS, Quinn PF, et al. Dosing of amoxcillin/clavulanate given every
12 hours is as effective as dosing every 8 hours for treatment of lower respiratory
tract infection. Clin Infect Dis 1997;24(4):570-4.
75
CAP Guidelines
28. Grimaldo ER, Tupasi TE, Rivera AB, et al. Increased resistance to ciprofloxacin
and ofloxacin in MDR-MTB isolates from patients seen at a tertiary hospital in the
Philippines. Int J Tuberc Lung Dis 2001;5(6):546-50.
29. Williams JH. Fluoroquinolones for respiratory infections: too valuable to overuse.
Chest 2001;120(6):1771-5.
31. Ortiz MF, Comia CT. Adherence of the physicians at Mary Mediatrix Medical Center
to the 2004 Philippine Guidelines on the Management of Patients Hospitalized for
CAP. (unpublished)
32. San Diego DC, Galvez BB, Balanag VM, Naval S. Philippine clinical practice guidelines
of high-risk community-acquired pneumonia: a surveillance study (unpublished)
33. Bernas GA, Galvez BB. Community-acquired pneumonia: etiology, clinical profile
and outcome. Scientific proceedings (LCP). 1996;Jan-June;4(1).
34. Comia C and Mendoza, M. The adherence of physicians at the Philippine General
Hospital to the 2004 Philippine Guidelines on the Management of Patients Hospitalized
for Community-acquired Pneumonia. Philippine Journal of Microbiology and
Infectious Diseases. 2006;35(3):5-17.
35. Ortiz M and Comia C. Adherence of the physicians at Mary Mediatrix Medical
Center to the 2004 Philippine guidelines on the Management of Patients Hospitalized
for Community-acquired Pneumonia (CAP)
38. Eliott JH, Anstey NM, Jacups SP et al. Community-acquired pneumonia in Northern
Australia: low mortality in a tropical region using locally-developed treatment
guidelines. Int J Infect Dis 2005;9(1):15-20.
76
CAP Guidelines 2010 Update
46. Al-Ali MK, Batchoun RG, Al-Nour TM. etiology of community-acquired pneumonia
in hospitalized patients in Jordan. Saudi Med J 2006;27(6):813-6.
47. Sohn JW, Park SC, Choi Y et al. Atypical pathogens as etiologic agents in hospitalized
patients with community-acquired pneumonia in Korea: a prospective multi-center
study. J Korean Med Sci 2006;21:602-7.
50. Yen MY, Hu BS, Chen YS. A prospective etiologic study of community-acquired
pneumonia in Taiwan. J Formos Med Assoc. 2005 Oct;104(10):724-30.
51. Lauderdale TL, Chang FY, Ben RJ et al. Etiology of community-acquired pneumonia
among adult patients requiring hospitalization in Taiwan. Respir Med 2005 Sep;
99(9):1079-86.
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CAP Guidelines
55. Saniel MC, Alejandria MM, Ecarma RM et al. Prevalence of atypical pathogens in
hospitalized patients with community acquired pneumonia in the Philippines, 2002.
(unpublished).
56. Okimoto N, Kurihara T, Honda N, et al. Clinical effect of ampicillin with beta-
lactamase inhibitor (sulbactam/ampicillin) on community-acquired pneumonia in the
elderly. J Infect Chemother 2003 Jun;9(2):183-6.
58. Ortiz G. Lopez J, Friedland I, et al. A study evaluating the efficacy, safety and
tolerability of ertapenem vs. ceftriaxone for the treatment of community-acquired
pneumonia in adults. Clin Infect Dis 2002;34(8):1076-83.
60. Frank E, Liu L, Kinasewitz G, et al. A multi-center open label, randomized comparison
of levofloxacin and azithromycin plus ceftriaxone in hospitalized adults with moderate
to severe community-acquired pneumonia. Clin Ther 2002;24(8):1292-308.
62. File T, Segreti J, Dunbar L, et al. A Multicenter, randomized study comparing the
efficacy and safety of intravenous and/or oral levofloxacin versus ceftriaxone and/
or cefuroxime axetil in treatment of adults with community-acquired pneumonia.
Antimicrob Agents Chemother 1997;41(9):1965-72.
63. Dresser LD. Cost-effectiveness of gatifloxacin vs ceftriaxone with a macrolide for the
treatment of community-acquired pneumonia. Chest 2001;119(5):1439-48.
64. Sanchez F, Mensa J, Martinez E, et al. Is Azithromycin the first choice macrolide for
treatment of community-acquired pneumonia? Clin Infect Dis 2003; 36(10):1239-45.
78
CAP Guidelines 2010 Update
65. Pena A, Roa C, Makalintal N, et al. Safety and efficacy of IV and oral azithromycin
in community-acquired pneumonia: results of an open, multi¬center study among
Filipino patients. Phil J Int Med 2003;41:51-8.
67. Plouffe JF, Breiman RF, Fields BS, et al. Azithromycin in the treatment of Legionella
pneumonia requiring hospitalization. Clin Infect Dis 2003;37(11):1475-80.
69. Feagan BG. A controlled trial of a critical pathway for treating community-acquired
pneumonia: the CAPITAL study assessing levofloxacin. Pharmacotherapy. 2001;
21(7 Pt 2):89-94S.
70. Hurst M, Lamb H, Scott L, Figgitt D. Levofloxacin: an updated review of its use in
the treatment of bacterial infections. Drugs 2002; 62(14):2127-67.
71. Dunbar L, Wunderink R, Habib M, et al. High-dose, short course levofloxacin for community-
acquired pneumonia: a new treatment paradigm. Clin Infect Dis 2003; 37:752-60.
72. Erard V, Lamy O, Bochud PY, Bille J, Cometta A, Calandra T. Full course oral
levofloxacin for treatment of hospitalized patients with community-acquired
pneumonia. Eur J Clin Microbiol Infect Dis 2004;23(2):82-8.
73. Lodise TP. Comparison of β-lactam and macrolide combination therapy versus
fluoroquinolone monotherapy in hospitalized Veterans Affairs patients with
community-acquired pneumonia. Antimicrobial Agents and Chemotherapy.
2007;51(11):3977-3982.
74. Metersky ML, Houck AMP and Bratzier DW. Antibiotics for bacteremic pneumonia.
Chest 2007;131:466-473.
75. Mufson MA, Stanek RJ: Bacteremic pneumococcal pneumonia in one American
City: a 20-year longitudinal study, 1978–1997.Am J Med 1999;107:34S-43S.
76. Waterer GW, Somes GW, Wunderink RG: Monotherapy may be suboptimal for
severe bacteremic pneumococcal pneumonia.Arch Intern Med 2001;161:1837-42.
77. Martinez JA, Horcajada JP, Almela M, Marco F, Soriano A, Garcia E, Marco MA,
Torres A, Mensa J: Addition of a macrolide to a beta-lactam-based empirical antibiotic
regimen is associated with lower in-hospital mortality for patients with bacteremic
pneumococcal pneumonia. Clin Infect Dis 2003,36:389-95.
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CAP Guidelines
78. Dudas V, Hopefl A, Jacobs R, Guglielmo BJ: Antimicrobial selection for hospitalized
patients with presumed community-acquired pneumonia: a survey of nonteaching US
community hospitals. Ann Pharmacother 2000;34:446-52.
79. Brown RB, Iannini P, Gross P, Kunkel M: Impact of initial antibiotic choice on
clinical outcomes in community-acquired pneumonia: analysis of a hospital claims-
made database. Chest 2003;123:1503-11.
80. Garcia Vazquez E, Mensa J, Martinez JA, Marcos MA, Puig J, Ortega M, Torres A:
Lower mortality among patients with community-acquired pneumonia treated with
a macrolide plus a beta-lactam agent versus a beta-lactam agent alone. Eur J Clin
Microbiol Infect Dis 2005;24:190-95.
81. Lin JC, Yeh KM, Peng MY, Chang FY. Efficacy of cefepime versus ceftazidime in the
treatment of adult pneumonia. J Microbiol Immunol Infect. 2001;34(2):131-7.
84. Finch RG, Pemberton K, Gildon KM. Pneumonia: the impact of risk factors on the
outcome of treatment with meropenem and ceftazidime. J Chemother 1998;1:35-46.
86. Ho A, Leung R, Lai CK, Chan TH, Chan CH. Hospitalized patients with community-
acquired pneumonia in Hong Kong: a randomized study comparing imipenem/cilastin
and ceftazidime. Respiration 1997;64(3):224-8; 64(4):303.
89. Covi M, Velluti G. Comparison of the efficacy and safety of isepamicin and amikacin
in the treatment of acute lower respiratory tract infections caused by Gram-negative
organisms. J Chemother 1995;7 Suppl 2:137-42.
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CAP Guidelines 2010 Update
91. D’Ignazio JD, Camere MA, Lewis DE and Jorgensen D, Breen JD. Novel, single-
dose microsphere formulation of azithromycin versus 7-day levofloxacin therapy
for treatment of mild to moderate community-acquired pneumonia in adults.
Antimicrobial Agents and Chemotherapy. October 2005: 4035-41.
92. Drehobl MA, De Salvo MC, Lewis DE et al. Single-dose azithromycin microspheres
vs clarithromycin extended release for the treatment of mild-to-moderate community-
acquired pneumonia in adults. Chest 2005 Oct;128(4):2230-7.
93. Tanaseanu C et al. Efficacy and safety of tigecycline versus levofloxacin for
community-acquired pneumonia. BMC Pulmonary Medicine 2009;9:44.
95. Halm E, Fine M, Marrie T, et al. Time to clinical stability in patients hospitalized with
community-acquired pneumonia. JAMA 1998;279:1452-7.
96. Pachon, J, Prados MD, Capote F, Cuello JA, Garnacho J, Verano A. Severe
community-acquired pneumonia: etiology, prognosis, and treatment. Am Rev Respir
Dis 1990;142: 369-73.
97. Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice
guidelines for the management of community-acquired pneumonia in adults.
Infectious Disease Society of America. Clin Infect Dis 2000;31:347-82.
99. Dans PE, Charache P, Fahey M, Otter SE. Management of pneumonia in the
prospective payment era: a need for more clinician and support service intereaction.
Arch Intern Med 1984;144:1392-7.
101. Mittl RL, Schwab RI, Duchin JS, Goih JB, Albeida SM, Miller W. Radiographic
resolution of community-acquired pneumonia. Am J Respir Crit Care Med 1994;149:
630-5.
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CAP Guidelines
103. Macfarlane, JT, Miller AC, Roderick Smith WH, Morris AH, Rose DH. Comparative
radiographic features of community-acquired legionnaires’ disease, pneumococcal
pneumonia, M. pneumoniae and psitacosis. Thorax 1984;39:28-33.
105. Grayston JT. Chlamydia pneumonia strain TWAR pneumonia. Ann Rev Med
1992;43:317-23.
106. Bruns AHW, Oosterheert JJ, Prokop M, Lammers JJ, Hak E, Hoepelman AIM.
Patterns of resolution of chest radiograph abnormalities in adults hospitalized with
severe community-acquired pneumonia. Clin Infect Dis 2007;45:983-91.
107. Hitt CM, Nightingale CH, Quintiliani R, Nicolau DP. Streamlining antimicrobial
therapy for lower respiratory tract infections. Clin Infect Dis 1997;24(Suppl 2):
S213-7.
109. Ramirez JA, Vargas S, Ritter G, et al. Early switch from IV to oral antibiotics and
early hospital discharge: a prospective observation study of 200 consecutive patients
with community acquired pneumonia. Arch Intern Med 1999;159:2449-54.
112. Halm EA, Fine MJ, Kapoor WN, Singer DE, Marrie TJ, Siu AL. Instability on
hospital discharge and the risk of adverse outcomes in patients with pneumonia. Arch
Intern Med 2002; 162:1278-84.
113. Ramirez JA, Bordon J. Early switch from intravenous to oral antibiotics in hospitalized
patients with bacteremic community-acquired Streptococcus pneumoniae pneumonia.
Arch Intern Med 2001;161(6):848-50.
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CAP Guidelines 2010 Update
116. Halm EA, Switzer G, Mittman B, Walsh M, Chang C, Fine M. What factors influence
physicians’ decisions to switch from IV to oral antibiotics for community-acquired
pneumonia? J Gen Intern Med 2001:16:599-605.
117. Cockburn J, Gibberd RW, Reid AL, Sanson RW. Determinants of non-compliance
with short-term antibiotic regimens. Br Med J 1987;295:814-18.
118. Oosterheert JJ, Bonten MJ, Schneider MM, et al. Effectiveness of early switch from
intravenous to oral antibiotics in severe community acquired pneumonia: multicenter
randomized trial. BMJ 2006;333:1193.
119. Arancibia F, Ewig S, Martinez JA, et al. Antimicrobial treatment failures in patients
with community-acquired pneumonia. Am J Respir Crit Care Med 2000; 162:154–
60.
120. Bernas GA, Galvez BB. Community-acquired pneumonia: etiology, clinical profile
and outcome. Phil J of Chest Dis 1997;5(1):31-9.
121. Finch RG, Woodhead MA. Practical considerations and guidelines for the management
of community-acquired pneumonia. Drugs 1998;55(1):31-45.
123. Menendez R, Torres A, Zalacain R, et al. Risk factors of treatment failure in community
acquired pneumonia: implications for disease outcome. Thorax 2004; 59:960–5.
124. Genne D, et al. Analysis of factors associated with early failure in hospitalized
patients with community-acquired pneumonia. European Journal of Microbiology
and Infectious Diseases 2006;25:159-66.
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CAP Guidelines
128. Myburgh J, Nagel GL, Perschel E. The efficacy and tolerance of a 3-day course of
azithromycin in the treatment of community-acquired pneumonia. J Antimicrob
Chemother 1993;31(Suppl E):163-70.
129. Zachariah J. A randomized, comparative study to evaluate the efficacy and tolerability
of a 3 day course of azithromycin versus a 10 day course of co-amoxiclav as treatment
for adult patients with lower respiratory tract infections. J Antimicrob Chemother
1996;37 Suppl C;103-13.
131. O’Doherty B, Muller O. Randomized, multicenter study of the efficacy and tolerance
of azithromycin versus clarithromycin in the treatment of adults with mild to moderate
CAP. Eur J Clin Microbiol Infect Dis 1998; 17:828-33.
133. File TM. Clinical efficacy of newer agents in short-duration therapy for community-
acquired pneumonia. Clin Infect Dis 2004; 39(Suppl 3): S159-64.
135. Plouffe JF, et al. Azithromycin in the treatment of Legionella pneumonia requiring
hospitalization. Clin Infect Dis 2003; 37:1475-80.
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CAP Guidelines 2010 Update
The Philippine CAP Task Force reviewed the current guidelines for
pneumococcal and influenza vaccines of the following groups: (1) Advisory
Committee on Immunization Practices (ACIP) of the Centers for Disease Control
and Prevention (Atlanta, Georgia); (2) Philippine Society for Microbiology and
Infectious Diseases with the Philippine Foundation for Vaccination (PFV); (3)
Philippine College of Chest Physicians Council on Pulmonary Infections; and
(4) Department of Health Technical Working Group for Influenza Prevention and
Management.3-7
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CAP Guidelines
While the ACIP recommends universal vaccination of PPSV23 for all adults
65 years of age and older, the recommended age in the Philippines is 60 years
of age and older. This is because the projected life expectancies in the country
are lower. According to DOH 2001 Statistics, the average life expectancy is 66.6
years for Filipino males and 71.9 years for Filipino females. In the 2009 update
of the “Handbook on Adult Immunization for Adult Filipinos,” vaccination of
PPSV23 is recommended for persons >50 years old.
Revaccination may be given to the following groups: (1) persons >65 years
who received their first dose more than 5 years ago and before they reached age
65; (2) persons <64 years old who received the vaccine more than 5 years ago and
who have asplenia, HIV, leukemia, lymphoma, generalized malignancy, multiple
myeloma, chronic renal failure, or nephritic syndrome; (3) persons receiving
immunosuppressive chemotherapy including corticosteroids; and (4) persons who
received solid organ or bone marrow transplant.5
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vaccine develop mild, local side effects (e.g., pain at the injection site, erythema,
and swelling). Moderate systemic reactions (e.g., fever and myalgias) and severe
systemic reactions (e.g., anaphylactic reactions) have rarely been reported. No
neurologic disorders (e.g. Guillain-Barré Syndrome) have been associated with
the administration of pneumococcal vaccine.3
Indications
• Persons aged >60 years of age
• Persons with chronic illnesses: chronic pulmonary diseases (chronic
obstructive pulmonary disease, bronchiectasis, chronic pulmonary
tuberculosis), cardiovascular (including congestive heart failure and
cardiomyopathies), diabetes mellitus, chronic alcoholism, chronic liver
disease, chronic renal failure or nephrotic syndrome, cerebrospinal fluid
leaks, functional or anatomic asplenia
• Immunocompromised persons: HIV/AIDS, lymphoma, leukemia, multiple
myeloma, generalized malignancy; those receiving immunosuppressive
chemotherapy or corticosteroids, solid organ or bone marrow transplant
• Residents of nursing homes and other long-term care facilities
• Smokers or asthmatic persons aged 19 to 64 years
Adult Dose
• Single 0.5 ml dose given intramuscularly or subcutaneously
One-time revaccination may be given to the following4 groups:
• Persons >65 years of age who received their first dose more than 5 years
ago and before they reached age 65
• Persons <64 years of age who received the vaccine more than 5 years
ago and who have the following: asplenia, HIV, leukemia, lymphoma,
generalized malignancy, multiple myeloma, chronic renal failure or
nephritic syndrome
• Persons receiving immunosuppressive therapy including corticosteroids
• Persons who received solid organ or bone marrow transplant
Precautions / Contraindications
• Immediate anaphylactic reaction to a previous dose of pneumococcal
vaccine
• Allergy to a vaccine component : anaphylaxis to phenol or thimerosal
• Moderate to severe illness with or without a fever
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Each year, the seasonal influenza vaccine contains three influenza virus
strains: one influenza A (H3N2) virus, one influenza A (H1N1) virus, and one
influenza B virus. The influenza virus strains in the vaccine are selected each year
based on surveillance-based forecasts about what virus strains are most likely to
cause illness in the coming season. Therefore, each year’s vaccine is designed
to protect against the influenza viruses expected to cause disease during that
influenza season.14 Vaccines prepared for a previous influenza season should not
be administered to provide protection for any subsequent season.4
The viruses used in making flu vaccine each year are based on information
gathered over the previous year about the strains of flu viruses that are infecting
humans and how they are changing. Circulating influenza strains and information
on disease trends are gathered by 122 national influenza centers in 94 countries
and the viruses and other data are further tested and combined data are analyzed by
the four World Health Organization (WHO) Collaborating Centers for Reference
and Research on Influenza located in Atlanta, London, Melbourne, and Tokyo.
Each country then can use the recommendations made by the WHO to
assist with national decisions about which viruses to use in influenza vaccines for
their country.14 For the Philippines, current recommendations now state that the
formulation for the Southern Hemisphere be used.
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The WHO has issued recommendations that influenza vaccines for the 2010
southern hemisphere season contain the following viruses: an A/Perth/16/2009
(H3N2)-like virus, a B/Brisbane/60/2008-like virus, and an A/California/7/2009
(H1N1)-like virus. This group of recommended influenza vaccine viruses will
cover both pandemic and seasonal influenza. The A/California/7/2009 (H1N1)-like
virus covers current pandemic influenza viruses, and the other two recommended
vaccine viruses cover seasonal influenza viruses for 2010 in the southern
hemisphere. Recommendations on the presentation of the vaccines—whether the
viruses should be contained in a single vaccine or in one for pandemic (H1N1)
2009 influenza and another for seasonal influenza—will be provided later.16
Influenza outbreaks have been reported among persons who travel from
the northern hemisphere to the southern hemisphere and among persons from the
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northern hemisphere on group tours. Any traveler who wants to reduce the risk
for influenza infection should consider influenza vaccination, preferably at least
2 weeks before departure. Influenza vaccination is recommended before travel
for persons at high risk for complications of influenza if they plan to travel to the
tropics at any time of the year, travel with organized tourist groups at any time of
the year, or travel to the Southern Hemisphere during April to September.3
The influenza vaccine should be stored at 2oC – 8oC and should not be
frozen. For adults, the influenza vaccine is administered at a dose of 0.5 mL
intramuscularly every year. Annual vaccination with the current vaccine is
necessary because immunity declines during the year after vaccination.
The previous 1976 swine influenza vaccine was associated with increased
frequency of Guillain-Barré Syndrome. Evidence for a causal relation of Guillain-
Barré Syndrome with subsequent vaccines prepared from other influenza viruses
is unclear. The likelihood of coincidentally experiencing Guillain-Barré Syndrome
after influenza vaccination is expected to be greater among persons with a history
of Guillain-Barré Syndrome than among persons with no history of this syndrome.
Whether influenza vaccination specifically might increase the risk for recurrence
of Guillain-Barré Syndrome is unknown. Therefore, avoiding vaccinating persons
who are not at high risk for severe influenza complications and who are known
to have experienced Guillain-Barré Syndrome within 6 weeks after a previous
influenza vaccination is prudent.3
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Indications
Adult Dose
Precautions / Contraindications
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SUMMARY OF EVIDENCE
a. Pneumococcal Vaccine
The pneumococcal vaccine is both cost effective and
protective against IPD.2 Postlicensure epidemiologic studies
have documented the vaccine’s efficacy in preventing IPD
among the elderly and individuals with certain chronic medical
conditions.20 Only one case-control study failed to demonstrate
effectiveness against bacteremic disease,19 possibly because
of study limitations such as small sample size and incomplete
ascertainment of patients’ vaccination status. Moreover, the
severity of underlying clinical conditions of case patients may
not have been comparable to that of the controls, creating a
potentially biased underestimate of vaccine effectiveness. The
overall efficacy against IPD among immunocompetent persons
65 years of age and older is 75%; however efficacy seems to
decrease with advancing age.22
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b. Influenza Vaccine
The effectiveness of influenza vaccine depends primarily
on the age and immunocompetence of the vaccine recipient
and the degree of similarity between the viruses in the vaccine
and those in circulation.3 The vaccine prevents influenza illness
in approximately 70–90% of healthy adults aged <65 years28,,29.
Influenza vaccination reduces the rates of visits to physicians,
sick leaves, and antibiotic use attributable to influenza-like
illness by 34 to 44%, 32 to 45%, and 25%, respectively.30
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c. Smoking Cessation
Data suggesst that cigarette smoking is the major avoidable
risk factor for acute pneumonia in adults.34 In a population-
based case-control study by Nuorti et al.35, cigarette smoking
was identified as the strongest independent risk factor for
IPD among immunocompetent, nonelderly adults. IPD was
associated with cigarette smoking (OR, 4.1; 95% CI 2.4 to 7.3)
and with passive smoking among nonsmokers (OR 2.5; 95% CI
1.2 to 5.1).
REFERENCES
1. Centers for Disease Control and Prevention. Interim guidance for use of 23-valent
pneumococcal polysaccharide vaccine during novel influenza A(H1N1) outbreak.
www.cdc.gov/h1n1flou/guidance/ppsv_h1n1.htm
4. Centers for Disease Control and Prevention. Prevention and Control of Influenza:
Recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR (ACIP), 2009. MMWR July 31, 2009; 58 (No. RR-8):1-52.
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8. Capeding MRZ, Sombrero LT, Lucero MG, Saniel MC. Serotype distribution and
antimicrobial resistance of invasive Streptococcus pneumoniae isolates in Filipino
children. Jour Infect Dis 1994; 169:479-480.
12. Gross PA, Hermogenes AW, Sacks H, Lau J, Levandowski R. The efficacy of influenza
vaccine in elderly persons: a meta-analysis and review of literature. Ann Intern Med
1995;123 (7):518-27.
13. Mullooly JP, Bennett MD, Hombrook MC, et al. Influenza vaccination programs for
elderly persons: cost-effectiveness in a health maintainance organization. Ann Intern
Med 1994;121:947-52
14. Centers for Disease Control and Prevention. Questions and Answers: Selecting the
Viruses in the Influenza (Flu) Vaccine. www.cdc.gov/flu/professionals/vaccination/
virusqa.htm
15. Centers for Disease Control and Prevention. Use of Influenza A(H1N1) 2009
Monovalent Vaccine. Recommendations of thee Advisory Committee in Immunization
Practices (ACIP), 2009. MMWR August 28, 2009 / 58(RR10);1-8.
16. Recommended composition of influenza virus vaccines for use in the southern
hemisphere in the 2010 influenza season. www.who.int/entity/csr/disease/
influenza/200909. RecommendationFAQ.pdf.
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18. Govaert TM, Thijs CT, Masurel N, Sprenger MJ, Dinant GJ, Knottnerus JA. Efficacy
of influenza vaccination in elderly individuals: a randomized double-blind placebo-
controlled trial. JAMA 1994;272:1661-5
19. Margolis KL, Nichol KL, Poland GA, Pluhar RF. Frequency of adverse reactions to
influenza vaccine in the elderly: a randomized controlled trial. JAMA 1990;264:1139-
41
20. Butler JC, Shapiro ED, Carlone GM. Pneumococcal Vaccines: History, current status
and future directions. Am J Med. 1999; 107 (1A): 69S-76S.
21. Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent
pneumococcal polysaccharide vaccine. NEJM 1991; 325:1453-1460.
22. Forrester BL, Jahnigan DW, LaForce FM. Inefficacy of pneumococcal vaccine in a
high-risk population. Am J Med. 1987;83:425-430.
24. Fisman DN, Abrutyn E, Spaude KA, et al. Prior Pneumococcal Vaccination Is
Associated with Reduced Death, Complications, and Length of Stay among
Hospitalized Adults with Community-Acquired Pneumonia. Clin Infect Dis 2006;
42:1093-101.
25. Johnstone J, Marrie TJ, Eurich DT, et al. Effect of Pneumococcal Vaccination in
Hospitalized Adults With Community-Acquired Pneumonia. Arch Intern Med
2007;167(18):1938-1943.
26. Nichol KL, Baken L, Wuorenma J, Nelson A. The Health and Economic Benefits
Associated With Pneumococcal Vaccination of Elderly Persons With Chronic Lung
Disease. Arch Intern Med. 1999;159:2437-2442.
27. Moberley SA, Holden J, Tatham DP, Andrews RM, Vaccines for preventing
pneumococcal infection in adults. Cochrane Database of Systematic Reviews 2008,
Issue 1. Art. No: CD000422. DOI:10.1002/14651858.CD000422.pub2.
28. Wilde JA, Mcmillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC..
Effectiveness of vaccination against influenza in health care professionals. JAMA
1999;281(10):908-13.
29. Bridges CB, Thompson WW, Meltzer MI, et al. Effectiveness and cost benefit of
influenza vaccination in healthy working adults: a randomized controlled trial. JAMA
2000;284:1655-63.
30. Ahmed F, Singleton JA, Franks AL. Influenza vaccination for healthy young adults.
NEJM 2001; 345:1543-1547.
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32. Herrera G. et al. Influenza vaccine effectiveness among 50-64 year-old persons during
a season of poor antigenic match between vaccine and circulating influenza virus
strains : Colorado, United States, 2003-2004. VACCINE, Vol 25, Issue 1, January 2,
2007, pages 154-160.
34. Farr BM, Bartlett CI, Wadsworth J, Miller DL. Risk factors for community-acquired
pneumonia diagnosed upon hospital admission. British Thoracic Society Pneumonia
Study Group. Respir Med. 2000 Oct;94 (10) : 954-63.
35. Nuorti JP, Butler JC, Farley MM, et al. and The Active Bacterial Core Surveillance
Team. Cigarette Smoking and IPD. N Engl J Med 2000;342:681-9.
36. Baik I, Curhan GC, Rimm EB, et al. A Prospective Study of Age and Lifestyle Factors
in Relation to Community-acquired Pneumonia in US Men and Women. Arch Intern
Med 2000;160:3082-3088.
37. Almirall J, Bolibar I, Serra-Prat M, et al. New evidence of risk factors for community-
acquired pneumonia: a population-based study. Eur Respir J 2008; 31: 1274-1284
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APPENDICES
Grade Definition
Strength of recommendation
Quality of evidence
REFERENCE
Kish MA. Guide to development of practice guidelines. Clin Infect Dis 2001;
32:851–4.
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REFRENCES
1. Cunha, Burke A. Severe Legionella pneumonia: rapid presumptive diagnosis with
Winnthrop-University hospital’s weighted point score system (modified). Heart Lung
2008; 37: 311-320.
2. Cunha BA, editor. Pneumonia essentials. 2nd ed. Royal Oak Michigan: Physicians Press; 2008.
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